Impact of liver donation on quality of life and physical and psychological distress

Our objectives were to assess the characteristics of donors for living-donor liver transplantation (LDLT) and to examine the impact of donation on LDLT donor quality of life (QOL) regarding physical and psychological distress. METHODS: Data were collected from a mailed survey or an interview using a cross-sectional prospective study design. We used the abbreviated version of the World Health Organization Quality of Life (WHOQOL-BREF), Physical Symptom Disturbance Scale, and Psychological Distress Scale. LDLT donors were recruited from a teaching hospital located in a metropolitan area of northern Taiwan. RESULTS: The 35 LDLT donors have a mean age 34.0 +/- 8.6 years and were recruited at a median of 25.9 months after donation (range, 0.6-92 months). The average scores in the four domains of the WHOQOL-BREF scale ranged from 13.5 to 14.9. LDLT Donors reported higher QOL scores in social and environment domains but lower scores in physical and psychological domains than healthy adults. Numbers of physical symptoms experienced by each donor ranged from one (n = 4) to 27 (n = 2). Feeling throbbing, itching or numbness around the wound was the most common physical symptom disturbance reported by donors (n = 26, 74%). Approximately 40% of the donors reported having one to three metrics of psychological distresses. "Easily feel distress and angry" was the most common psychological distress reported by 57% (n = 20) of donors. CONCLUSIONS: This study indicated that liver donation had a mild negative impact on donors physical and psychological facets of QOL. These results may assist professionals to provide appropriate clinical management.     

Comparison between psychosocial long-term outcomes of recipients and donors after adult-to-adult living donor liver transplantation

The purpose of this study was to examine psychosocial states of recipients and donors several years after living donor liver transplantation (LDLT) and to find out the pre-transplant predictors of desirable post-transplant psychosocial states. The recipients and donors of adult-to-adult LDLT at Kyoto University Hospital, Japan, from November 2001 through July 2003 were interviewed and examined by means of questionnaires about anxiety, depression, and quality of life (QOL), and the participants were evaluated by the same test batteries sent by mail three to five yr after LDLT. Twenty-seven pairs of recipients and donors, 13 recipients, and three donors participated in this study. The recipients and the donors had a decline in social QOL. The main predictor of psychosocial states of the recipients was the length of wait for LDLT, and the predictors of the donors were family or support system availability and recipients' depressive states at LDLT. The donors who were spouses of the recipients had better QOL than other donors. It might be better to perform LDLT as soon as possible once LDLT has been judged to be necessary, and the relative who is on close terms with the recipient should be selected as donor.     

Living Donor Liver Transplantation for Acute Liver Failure: A Single Center Experience

Objective

Orthotopic liver transplantation (OLT) is the principal therapy for acute liver failure (ALF). The mortality on the waiting list for deceased donor liver transplantation (DDLT) is high, principally in countries where donation rates are low. Living donor liver transplantation (LDLT) seems an option for the treatment of ALF, although some ethical issues need to be considered. Herein we have evaluated LDLT results among patients with ALF and discussed the ethical aspects of procedures performed in emergency situations.

Patients and Methods

From March 2002 to October 2008, we performed 301 liver transplantations, including 103 from living donors. ALF was responsible for 10.6% of all transplantations; LDLT was only considered for pediatric recipients among whom 7 children displayed ALF.

Results

One patient died on postoperative day 33 due to hepatic artery thrombosis. One patient died at 2 months after transplantation due to biliary sepsis, resulting in an overall survival rate of 71%. The average time for donor discharge was 5 days. No mortality or major complications were observed.

Conclusions

The survival of children with ALF undergoing LDLT was comparable to published data. Furthermore, despite the fact that the available time to prepare the donors was limited, no serious complications were observed in the postoperative period. Thus, using living donors for children with ALF is an effective, safe alternative that can be extremely useful in countries with low donation rates.     

Outcomes of Living Versus Deceased Donor Liver Transplantation for Acute Liver Failure in the United States

Clinical outcomes for living donor liver transplantation (LDLT) for acute liver failure (ALF) in the United States remain to be determined. To address this gap in knowledge, we examined post–liver transplantation outcomes of adults with ALF undergoing LDLT and deceased donor liver transplantation (DDLT) in the United States. We analyzed Organ and Procurement and Transplantation Network data for adults with ALF who were listed for liver transplantation as status 1 or 1A and who underwent LDLT (N = 21) or DDLT (N = 2316) between October 1987 and April 2011. We found no strong evidence that the survival probabilities for adults with ALF who underwent LDLT were inferior to those who underwent DDLT (P = .764). In adults with ALF who underwent LDLT, 1- and 5-year survival probabilities were both 71%; for DDLT these probabilities were 79% and 71%, respectively. In adults with ALF, 1- and 5-year liver graft survival probabilities, respectively, were 62% and 57% for LDLT, and 74% and 66% for DDLT. In these series of adults with ALF who were listed as status 1 or 1A, patient and graft survival rates for LDLT were similar to those for DDLT. Our findings suggest that if deceased donor livers are unavailable, LDLT is an acceptable option in experienced centers for adults with ALF.     

Live Donor Liver Transplantation: A Valid Alternative for Critically Ill Patients Suffering From Acute Liver Failure

We report the outcome of live donor liver transplantation (LDLT) for patients suffering from acute liver failure (ALF). From 2006 to 2013, all patients with ALF who received a LDLT (n = 7) at our institution were compared to all ALF patients receiving a deceased donor liver transplantation (DDLT = 26). Groups were comparable regarding pretransplant ICU stay (DDLT: 1 [0–7] vs. LDLT: 1 days [0–10]; p = 0.38), mechanical ventilation support (DDLT: 69% vs. LDLT: 57%; p = 0.66), inotropic drug requirement (DDLT: 27% vs. LDLT: 43%; p = 0.64) and dialysis (DDLT: 2 vs. LDLT: 0 patients; p = 1). Median evaluation time for live donors was 24 h (18–72 h). LDLT versus DDLT had similar incidence of overall postoperative complications (31% vs. 43%; p = 0.66). No difference was detected between LDLT and DDLT patients regarding 1‐ (DDLT: 92% vs. LDLT: 86%), 3‐ (DDLT: 92% vs. LDLT: 86%), and 5‐ (DDLT: 92% vs. LDLT: 86%) year graft and patient survival (p = 0.63). No severe donor complication (Dindo–Clavien ≥3 b) occurred after live liver donation. ALF is a severe disease with high mortality on liver transplant waiting lists worldwide. Therefore, LDLT is an attractive option since live donor work‐up can be expedited and liver transplantation can be performed within 24 h with excellent short‐ and long‐term outcomes.     

活体肝移植治疗HBV相关性急性亚急性肝功能衰竭

目的 探讨活体肝移植(living donor liver transplantation,LDLT)HBV感染导致的急性肝功能衰竭(acute liver failure,ALF)和亚急性肝功能衰竭(subacute liver failure,SALF)患者的可行性,并评价其疗效.方法 回顾性分析2000年11月至2007年10月完成的10例LDLT治疗ALF、SALF患者的临床资料.10例LDLT的供、受者均为成人,切取右半肝为移植物,8例含肝中静脉(middle hepatic vein,MHV).10例供者的评估均在确定实施LDLT的24 h内完成,供、受者手术均在确定供者后的12 h内完成.移植物质量与受者体质量比为(1.03±0.17)%(0.86%～1.22%),移植物体积与受者标准肝体积比为(52.2±11.8)%(47.6%～70.1%).结果 10例受者中,2例分别于术后7、28 d时因肺部感染、十二指肠球部溃疡穿孔腹腔感染死亡.1例胆管吻合口胆漏,经十二指肠镜下置入鼻胆管引流治愈.2例术后1周出现轻度急性排斥反应,增强免疫抑制强度后肝功能恢复正常.8例中位随访期9.6个月(2～84个月),生存质量优良.10例供者中,1例出现急性门静脉高压症导致脾脏破裂,行脾脏切除术,其后出现胆管断端胆漏,经鼻胆管引流结合经皮穿刺腹腔引流治愈.其余9例无并发症发生.结论 LDLT适宜治疗HBV感染导致的ALF、SALF,而且能获得较好的中、远期疗效.     

Dual left lobe living donor liver transplantation using donors unacceptable for right lobe donation: a case report

Living donor liver transplantation (LDLT) has become a viable alternative for end-stage liver disease. The shortage of brain-dead donors has led to development of advanced surgical approaches. Dual lobe LDLT has been performed successfully in the recent years. The major indication for this complex procedure has been insufficient graft size from a single donor or insufficient remnant in the donor. We performed a dual left lobe LDLT using 2 donors who were unacceptable for right lobe donation.     

Live donor liver transplantation for acute liver failure

BACKGROUND: Acute liver failure (ALF) carries a high mortality unless urgent orthotopic liver transplantation (OLT) is performed on time. Live donors are utilized to treat this irreversible condition first in pediatric cases and then in adults. Herein, we aimed to report our experience with live donors for ALF in a country of a deceased donor organ donation rate is only 1.5 per million people. METHODS: Among the 245 live donor liver transplantations (LDLT) performed from June 1999 to December 2005, 14 of them (6%) were performed for ALF in 8 pediatric and 6 adult cases. Right lobes were harvested for the adult cases whereas left lateral segments were harvested for pediatric cases, except one child transplanted with a right lobe graft. The etiology of the disease was; acute hepatitis B in four cases, hepatitis A in three cases, Wilson disease two cases, autoimmune hepatitis in two cases, and was unknown in three cases. RESULTS: Three-year graft and patient survival is 79% for these series. Five of the six adult patients and six of the eight pediatric cases survived after transplantation. There was not any donor mortality or major morbidity. CONCLUSIONS: LDLT offers a safe and effective modality of treatment for ALF for both pediatric and adult patients to overcome the problem of organ shortage especially in countries where the chance of receiving an organ from a deceased donor is low.     

Psychosocial outcome of living donors after living donor liver transplantation: a pilot study

In view of the scarcity of organ resources available for transplantation, living donor liver transplantation (LDLT) is gaining growing importance in the treatment of chronically terminal liver diseases. In the period between December 1999 and October 2000, 47 potential living liver donors were evaluated and 24 right hepatic lobes and two left lateral segments were transplanted at the Virchow-Klinikum of the Charité Hospital in Berlin. The present study looks into biomedical and psychosocial parameters of 23 donors before and 6 months after LDLT. Our aims were to investigate the development of psychosocial parameters after donation and the relationship between psychosocial findings and post-operative complications. Most donors showed an improved quality of life (QoL) after LDLT when compared with pre-operative results. Twenty-six percent of donors show high values for 'tiredness', 'fatigue' and 'limb pain' following donation. The post-operative complications had no influence on the psychosocial outcome. In this pilot study the resection of the right hepatic lobe amounts to a safe operation for donors and holds promise of a good psychosocial outcome for most donors, irrespective of donation-related complications. The pronounced complaints appears to indicate psychological tension and distress in some donors following donation.     

Clinical Outcomes and Evaluation of the Quality of Life of Living Donors for Pediatric Liver Transplantation: A Single-Center Analysis of 100 Donors

There are few reports about the quality of life (QOL) and morbidities of pediatric living donor liver transplantation (LDLT) donors. We evaluated the potential morbidities and identified the predictive factors regarding the QOL of living donors after pediatric LDLT. This cross-sectional study was a single-center analysis of 100 donors for pediatric LDLT. The severity of morbidities was assessed with the Clavien classification, the QOL was investigated with the short form-36 (SF-36), and the decision-making process regarding donation was analyzed with questionnaires. The median follow-up period was 3.8 years (range, 2.2–6.0 years). A total of 13% of the donors developed postoperative complications of Clavien grades I (7%), II (3%), and IIIA (3%). There was no grade IV morbidity or mortality. Eighty-one donors responded to the questionnaire and SF-36. The analysis of the questionnaires revealed that the donors had difficulty in the decision-making process, and suggested that it may be necessary to administer multistep informed consent. We identified unique predictive risk factors for lower SF-36 scores in the donors, which were the time to donation (more than 4 weeks) and the predonation self-oriented perception. The donors who have risk factors require enhanced pre- and post-donation psychological care.     

Relevant factors to psychological status of donors before living-related liver transplantation

BACKGROUND: While previous surveys have demonstrated the psychological impact on living-related liver transplantation (LRLT) donors, such as anxiety, depression, ambivalence and anger, the details regarding the relevant factors that affect donors' psychological status have not been well described. METHODS: To evaluate environmental factors, 66 donors were interviewed to obtain information regarding donors' decision-making motivation, process, conflicts, and internal pressure about donation just before surgery. To determine the donors' psychological status, they completed the State-Trait Anxiety Inventory, Beck Depression Inventory, and World Health Organization Quality of Life 26 standardized psychological tests for anxiety, depression, and quality of life (QOL). Respective recipients completed the same tests separately, in order to determine psychological synchronization with the donors. With regard to motivation, donors were divided into two groups, and further divided into three groups based on processes. Donors were also sorted in groups of those "with conflict" and "with pressure." Their psychological test results were compared within groups, as well as with those from recipients. RESULTS: Donors from the nonvolunteer or postponement groups were significantly more anxious and depressed than other donors. Donors from the "with conflict" or "with pressure" groups were significantly more anxious, more depressed, and had worse QOL. There was a significant positive correlation between donors' and recipients' test results for anxiety and QOL, especially when donors belonged to the volunteer group. CONCLUSIONS: Our results suggest that donors' decision-making process and recipients' psychological status, especially donors' state anxiety should be considered when assessing donors' psychological status before LRLT.     

Who decides? Living donor liver transplantation for advanced hepatocellular carcinoma

Few effective treatment options are available for patients with advanced hepatocellular carcinoma (HCC). Some transplant centers have begun offering living donor liver transplantation (LDLT) for selected patients whose HCC exceeds Milan criteria by a small margin. However, this remains a controversial subject. In this article, we weigh the arguments for and against LDLT for advanced HCC. Because donor autonomy forms the crux of this dilemma, the real question becomes: to whom does the decision belong, the individual donors or the medical community? We argue that donor autonomy should not be paramount in settings where the recipient benefit is uncertain.     

Recent Advance in Living Donor Liver Transplantation

Living donor liver transplantation (LDLT)has been performed in more than 2000 cases around the world. This procedure is considered to have certain advantages over cadaveric liver transplantation, because detailed preoperative evaluation of the donor liver is possible and superior graft quality is available. The indication has recently been widened to include adult patients. The results of LDLT have been reported to be very good. In this article,several considerations on LDLT,including living donor selection and application to adult patients, are discussed. Between June 1990 and March 2001, 143 patients underwent LDLT at Shinshu University Hospital. During this period, 160 patients were determined to be candidates for liver transplantation in our institution, and 185 candidates were evaluated as potential donors for these patients. Thirty-eight of 185 donor candidates were excluded for reasons including liver dysfunction and withdrawal of consent. The recipients included 60 adults, 50 (83%) of whom are currently alive. Taking into account the worldwide shortage of cadaveric organ donation,the importance of LDLT will probably never diminish. This procedure should be established on the basis of profound consideration of donor safety as well as accumulated expertise of hepatobiliary surgery.     

Psychosomatische Aspekte der Leberlebendspende

Living donor liver transplantation (LDLT) offers the option to reduce organ scarcity and thereby waiting list mortality. The crucial ethical problem of LDLT is the fact that the well being of a donor is being jeopardized for the improvement of quality of life of the recipient. To preserve mental health of the donors, psychosomatic evaluation should be conducted including examination of the coping capacity, the mental stability of the donor and the voluntary nature of the donation. Thus a comprehensive disclosure of information to donors is necessary. Realistic outcome expectations, family relationships without extreme conflicts, sufficient autonomy of the donor-recipient relationship and social and familiar support are predictors facilitating a favorable psychosocial outcome for the donor. Before and after LDLT the health-related quality of life of the donors is similar or increased in comparison to the general population. Psychiatric complications following LDLT can occur in 13% of the donors. Female donors, donors who have surgical complications themselves and donors with unrealistic outcome expectations should be given psychotherapeutic support before they are admitted to living liver donation. Urgent indications in the case of acute liver failure and the donation by adult children for their parents are particular stress factors. For the safety of the donor, these combinations should be avoided whenever possible.     

Adult living‐related liver donation for acute liver failure: is it ethically appropriate?

Carlisle EM, Angelos P, Siegler M, Testa G. Adult living‐related liver donation for acute liver failure: is it ethically appropriate?
Clin Transplant 2011: 25: 813–820.
© 2011 John Wiley & Sons A/S. Abstract: Acute liver failure (ALF) results in the annual death of approximately 3.5 per million people in the United States. Unfortunately, given the marked shortage of cadaveric liver donations and the ethical questions that plague utilization of living donor liver transplantation (LDLT) for ALF, many patients with ALF die before a liver is allocated to them. In this review, we discuss how the consistent utilization of LDLT for ALF could decrease the mortality rate of ALF. Additionally, we examine a key underlying issue: is LDLT for ALF ethically appropriate?     

Psychosocial Assessment of Donors in Pediatric Living Donor Liver Transplantation: A Systematic Review

BackgroundPediatric living donor liver transplantation (LDLT) is the only way to save children with end-stage liver disease. The donor for liver transplantation (LT) may have a complicated psychosocial condition.PurposeThis review aims to identify the domains of the donor psychosocial questions that should be addressed and summarize the aspects and tools future psychosocial assessments should include.MethodsWe searched the PubMed, Medline, Cochrane Library, Embase, Web of Science, and Google Scholar databases for the terms pediatric, liver transplantation, donor, and psychosocial. We used the Joanna Briggs Institute Critical Appraisal Tool to appraise reporting quality. Two researchers independently selected the papers and performed data extraction and quality appraisal.ResultsThe articles included in this review contain 26 quantitative studies and 2 qualitative studies. The study quality was moderate to high. Donors have ambivalence, anxiety, the need for family and social support, the need for adequate information, distress, and low self-esteem during the preoperative period. In the postoperative period they have poor psychological condition, panic disorder, conversion disorder and substance use/abuse disorder, abnormal family functioning, better psychosocial outcome, or among others. The assessment methods consisted of the questionnaire survey and semi-structured interview. Among the 28 studies, 17 different psychosocial domains were mentioned. The most frequently referred to was family and social support.ConclusionThe contents of the psychosocial assessment must include anxiety or depression, family and social support, ambivalence, information, and positive psychosocial characteristics. Assessment methods should use the questionnaire survey and semi-structured interview. According to this review, future research can develop a specific psychosocial assessment tool for pediatric LT donors.     

Selection of liver-transplant candidates for adult-to-adult living donor liver transplantation as the only surgical option for end-stage liver disease.

The selection of living donor liver transplantation (LDLT) recipients in regions where deceased donor liver transplantation (DDLT) is rarely performed might be different from that in other centers at which LDLT is an alternative option to DDLT. Records of adult (age > or = 18 yr) patients referred to our center were reviewed to analyze the selection process of LDLT candidates. Among the 533 LDLT candidates, 165 (31%) were rejected due to recipient issues. Advanced hepatocellular carcinoma (HCC) was the most common reason for rejection (n = 55). Among the remaining recipients, 120 patients (22%) were rejected due to donor issues. LDLT was eventually performed in 249 (47%) of the evaluated recipients. There are few options for candidates who are unable to find live donors in regions where DDLT is unrealistic. A more effective and precise approach to recipient and donor evaluation should be pursued.     

Liver Transplantation for Hepatocellular Carcinoma

Background Orthotopic liver transplantation (OLT) is the best available option for early hepatocellular carcinoma (HCC), although its application is limited by stringent selection criteria, costs, and deceased donor graft shortage, particularly in Asia, where living donor liver transplant (LDLT) has been developed. Methods This article reviews the present standards for patient selection represented by size-and-number criteria with particular references to Milan Criteria and novel prediction models based on results achieved in patients exceeding those limits, with consideration of the expanded indication represented by the UCSF Criteria. Results The expected outcomes after deceased donor liver transplant (DDLT) or LDLT are favorable if predetermined selection criteria are applied. However, selection bias, difference in waiting time, and ischemia-regeneration injuries of the graft among DDLT vs LDLT may influence long-term results. In the article, the differences between East and West in first-line treatments for HCC (resection vs transplantation), indications, and ethics for the donor, are summarized as well as possible novel predictors of tumor biology (especially DNA mutation and fractional allelic loss, FAI) to be considered for better outcome prediction. Conclusions Liver transplantation remains the most promising product of modern surgery and represents a cornerstone in the management of patients with HCC. Proceedings of the Fifth International Meeting Hepatocellular Carcinoma: Eastern and Western Experiences held in Houston, TX, January 11–13, 2007.     

Toward 300 liver transplants a year

The technical success of cadaveric whole-size liver transplantation and better immunosuppressive drugs has extended the application of this life-saving procedure to include patients with irreversible acute and chronic liver diseases. However, because of the scarcity of cadaveric liver grafts, living-donor liver transplantation (LDLT) has emerged as an alternative to cadaveric-donor liver transplantation (CDLT), especially in Asia. In Korea, 8% of the population are hepatitis B virus (HBV) carriers, and the resultant HBV cirrhosis, with or without hepatocellular carcinoma (HCC), is common in the 40- to 60-year-old generation. Accordingly, many patients require orthotopic liver transplantation (OLT). In 1992, we started performing CDLTs in the Asan Medical Center. In 1994, the first successful pediatric LDLT was performed in Korea, on a 9-monthold infant with biliary atresia. In 1997, the first successful adult LDLT was performed in our department, using a left lobe, on a 37-year-old patient with HBV cirrhosis associated with HCC. Even after the first successful right-lobe LDLT, we faced the obstacle of anterior segment congestion of a right-lobe graft, and initiated reconstruction of the middle hepatic venous tributaries of a right-lobe graft in 1998. In 1999, we performed more than 100 OLTs a year. Insufficient graft size has hindered the expansion of adult LDLT, when the remaining left-lobe of potential donors is too small to assure donor safety. Dual two-left-lobe graft LDLT (transplanting from two donors into one recipient) was developed in 2000 to solve graft-size insufficiency and minimize donor risk. More than 200 OLTs a year have been performed since 2004, while broadening the indications for adult LDLT to near complete obstruction of the portal vein, with the application of intraoperative portography (IOP) and portal vein stenting. In 2007, 320 LTs were performed, including 276 adult LDLTs, 10 pediatric LDLTs, and 34 CDLTs (including 7 adult and 1 pediatric split-liver transplant). There has been no donor mortality in LDLT. With technical refinement and advanced perioperative care, the in-hospital mortality of recipients has dropped to 4%: attributed to the dedication of our liver transplantation team members.